The Usefulness of Incorporating Non-pathomorphological
Data Recorded in the Hospital Information System into the
Pathology Report Form and a Standardized Method of
Viewing Digital Pathology Images
Keizo Furuya, Toshiharu Maeda, Takanori Kikuchi
Department of Pathology and Radiology,
Ehime Prefectural Central Hospital
古谷敬三 Oct. 25, 2010 Pathology Vision 2010 (San Diego)
Hospital information system of Ehime Prefectural Central Hospital (2010)
Imaging system modalities
RIS system
Laboratory testing machines
Internet
Router
LIS system
Virtual slide
server
Subsystems
Library
PC PC
Electronic
patient
record
Pathology
system
PC
F/W machine
Hospital LAN
system
Virtual slide end
Exchange of information
through removable media
(2013)
New information s ys tem in O ur New Hos pital (2013)
to utilize accumulated data in HIS
Today’s presentation:
#Structured pathology report
#Seamless viewing images
L ab. s ys tem
#Medical library
S tatistical
data
専用D ata Warehous e
R IS ・
P AC S
S earch engine
C as e data
E lectronic
patient record
D ata
optimiz atio
n
D ata base
P athology
s ys tem
Constitution
1. Background
2. Aim
3. Materials and methods
3a. Pathology report form
3b. Seamlessly viewing images
3c. Medical library
4. Result
5. Conclusion
Changes in the filed of pathology over the
past several decades
Pathologists have confined themselves within a static
microscopic world.
On the other hand, medical fields other than pathology,
including imaging diagnosis and molecular and genomic
medicine, have developed remarkably.
The work of clinicians is comprehensive and dynamic
because of constant changes in patient states.
Medical record description by POMR (problem oriented medical record)
First medical examination
1. Data base
1) Patient information: patient profile, chief complaint, history of present illness, past history, family history,
social history, system review, etc.
2) Physical examination findings: general status (external appearance, mental state, skin condition) specific
status
3) Test findings
2. Problem list：disease name, signs and symptoms, patient’s condition or findings, etc.
1) #1 title, #2 title, #3 title--2) Distinguish active title from inactive title
3. Initial plan
1) Diagnostic plan: to select the diagnostic tests and plan a schedule for enforcement, e.g. urine tests,
blood tests, blood biochemistry tests, immunoserum tests, chest and abdominal plain X-rays, ECG, urine
culture and blood culture tests and abdominal US etc
2) Therapeutic plan
3) Education plan
Second medical examination or since the second day after admission
4. Progress note
1) Narrative note
S: subjective data (patient complaint)
O: objective data (physical findings and test findings）：
A: assessment (each problem is analyzed on the basis of the information available about the disease
and a hypothesis is established on what happens and why)
P: plan (make plans to prove the correctness of the hypothesis and describe it)
Imaging examinations (CT scan, MRI scan, etc.) and pathological examination
2) Flow chart
Record at discharge
5. Discharge summary
Provide a brief description, so it is understood easily by all who read it.
Clinicians
As for the daily duties, clinicians collect all kinds of clinical information and
summarize important data in progress notes to see patients.
Radiologists
Imaging diagnosis in radiology has converted from screen-film to digital monitor
diagnosis.
Radiologists read digital images by “Paging” as they give clinical signs and
symptoms, and laboratory data in mind.
Pathologists
Why do pathologists not move out from their static narrow minded pathomorphological world and include factors other than pathomorphological
findings into pathological diagnosis reports at least from the standpoint
of medical education?
“FDG PET-positive lung cancers with a high SUV have been
considered to represent a more malignant disease process,
resulting in a significantly worse survival rate.”
Park CM, Goo FM, Lee HF, et al.
Tumors in the tracheobronchial tree: CT and FDG PET features.
RadioGraphics 2009; 29(1): 55-71. Downey RJ, Akhurt T, Gonen M, et al.
Preoperative F-18 fluorodeoxyglucose-positron emission tomography
maximal standardized uptake value predicts survival after lung cancer
resection. J Clin Oncol 2004; 22: 3255-3260.
“---most pheochromocytomas accumulate FDG, uptake is found
in a greater percentage of malignant than benign pheochromocytomas, and FDG PET is especially useful in defining the
distribution of those ---.”
Blake MA, Cronin CG, Broland GW.
Adrenal imaging. JR 2010; 194:1450-1459
FDG, METO (11C-metomidate: a marker of 11-beta-hydroxylase), FETO, MIBG (metaiodobenzylguanidine),
HED (11C-hydroxyephedorine), F-DOPA
Constitution
1. Background
2. Aim
3. Materials and methods
3a. Pathology report form
3b. Seamlessly viewing images
3c. Medical library
4. Result
5. Conclusion
[Aim]
To examine the usefulness of incorporating non-pathomorphological
data recorded in the HIS (hospital information system) into the
pathology report form and the applicability of a standardized method
for viewing digital pathology images.
Constitution
1. Background
2. Aim
3. Materials and methods
3a. Pathology report form
3b. Seamlessly viewing images
3c. Medical library
4. Result
5. Conclusion
[Materials and Methods 3a]
Information was acquired from the HIS, including
the electronic patient record and findings of radiology, pathology,
and laboratory tests.
The pathology report form has the “diagnosis” and “findings”
sections, as before, but are structured like research papers.
Imaging system modalities
RIS system
Laboratory testing machines
Internet
Router
LIS system
Virtual slide
server
Subsystems
Library
PC PC
Electronic
patient
record
Pathology
system
PC
F/W machine
Hospital LAN
system
Virtual slide end
Exchange of information
through removable media
Structured pathology report in the environment of HIS
One case is considered as one research paper
Diagnosis (abstract including the clinician’s requirements)
Findings:
1) Handling of specimens (materials and methods)
2) Patho(morpho)logical description (results)
Incorporation of non-pathomorphological data such as
radiological data (glucose uptake in PET-CT scans),
results of laboratory tests (tumor markers), etc,
with the date of each test.
3) Comment (discussion)
Incorporation of substantial comments by utilizing our
medical library containing research papers on the cases
in our hospital.
Structured pathology report: surgically resected cases
Case 1: 73-year-old man
Chief complaint: liver tumor detected at the follow-up CT imaging after gastrectomy
for gastric cancer
Clinical diagnosis: liver cancer suggestive of a combined type HCC (hepatocellular carcinoma),
CCC (cholangiocellular carcinoma), or metastatic carcinoma
Diagnosis: Liver, partial hepatectomy: hepatocellualr carcinoma, Lo S7/8, size 4.0×3.1 cm,
necrosis 10%, eg+ig, fc+, fc-inf+, sf-, s+, vp+, vv-, b-, im+, p-, tw＝0.3 cm
Findings:
1) Materials: The resected liver was cut into 15 slices and slices 7, 8, and 11 with the main
tumor and slice 2 with a metastatic nodule were examined microscopically.
2) Findings: Grossly, the tumor is basically of the nodular type but of the partly confluent
multinodular type. Microscopically, the tumor consisted of 2 different patterns of HCC: the
trabecular type with a thickness of 5－10 cells and the combined trabecular and
pseudoglandular types consisting of stronger cellular atypia. Hence this tumor is a moderately
to poorly differentiated HCC. The tumor invades the liver surface exposed in the
abdominal cavity. [(Aug. 18, 2010) AFP 33.7H, PIVKA Ⅱ2180H, DUPAN-2 ≦25,
SPAN-2 13.8, CA19-9 177.8H, CEA 1.3; (Aug. 25, 2010) GLU 152H, HbA1c 6.0H;
(Aug. 19, 2010) PET-CT FDG-SUVmax = 4.8 (background liver 2.2)]
The tumor in segment 8 exhibits similar microscopic findings as the main tumor, so it is
identified as metastatic.
Liver: mild fatty change (non-B, non-C)
3) Comment: Contrast-enhanced MRI shows peripheral dominance in the early phase and
a low signal in the heptatocyte phase. The DWI (diffusion- weighted image) shows a high
signal. The imaging pattern and relatively high value of FDG SUVmax are not analogous
to typical HCC: however, the tumor is microscopically an HCC with moderate to poorly
differentiated cell components. These phenomena seem to be related to the microscopic
findings of 2 different patterns of HCC and the macroscopic findings of 2 gross types.
Structured pathology report: ESD (endoscopic submucosal dissection) case
Case 2: 63-year-old man
Clinical diagnosis: Early gastric cancer
Chief complaint: gastric polyp (introduced from an other hospital)
Diagnosis: Stomach, ESD: Early gastric cancer, type 0-Ⅰ+Ⅱa, sm1,
adenocarcinoma (por1+tub1), INFβ, 3.3×3.8×1.9 cm, location = M Gre,
ly2+, v0, lm- 0.3 cm, vm ± [C16.9/ICD-O 814031]
Findings:
1) Materials: The size of the excised specimen was 5.0×3.9 cm2, cut along
the short axis into 11 slices, and all slices were examined microscopically.
2) Findings: Grossly, the tumor is type 0-Ⅰ+Ⅱa and its size is 3.3×3.8×1.9
cm3 (see reference images).
Microscopically, the tumor is an adenocarcinoma (por1+tub1) and invades
into the submucosa (sm1). The vertical margin is in contact with the portion of
exhibiting lymphatic permeation. The lateral margin is tumor free. [(Sep. 01, 2010)
H. pylori antibody (+) 66.2 U/ml; CA19-9 3.9 U/ml; CEA 0.8 ng/ml]
3) Comment: The tumor is an adenocarcinoma of the gastric type, and foveolar
hyperplasia is observed in the background. Although it is difficult to clearly
differentiate between hyperplasia and neoplasia, the portion with structural
atypia in the hyperplastic epithelium is a very well differentiated
adenocarcinoma of the gastric type. Partial gastrectomy is recommended
because of a large poorly differentiated adenocarcinoma, ly2+, and vm±.
Constitution
1. Background
2. Aim
3. Materials and methods
3a. Pathology report form
3b. Seamlessly viewing images
3c. Medical library
4. Result
5. Conclusion
Every day clinicians observe various types of images including
radiological and gross pathological images using the HIS.
Hospital information system of Ehime Prefectural Central Hospital (2010)
Imaging system modalities
RIS system
Laboratory testing machines
Internet
Router
LIS system
Virtual slide
server
Subsystems
Library
PC PC
Electronic
patient
record
Pathology
system
PC
F/W machine
Hospital LAN
system
Virtual slide end
Exchange of information
through removable media
11
Reference CT and MRI images in the
electronic patient record are arranged
in the following order: from head to foot,
left to right, and top to bottom.
[Materials and Methods 3b]
All kinds of images including radiological, gross pathological and
histopathological images are arranged to be viewed seamlessly
as follows.
1) The resected gross specimens were sliced in the same planes as the
radiological axial images.
2) The slices were then placed on a photography table in the same order
as in the radiological images and were photographed.
3) All the gross slices and histology slides were assigned corresponding
numbers and
4) the glass histology slides were digitized by virtual microscopy.
HCC case: Gross pathology specimen
1
1)The resected gross specimens were sliced in
the same planes as the radiological axial images.
2)The slices were then placed on a photography table in the same order as in the
Radiological images and were photographed.
Gross pathology images are arranged in the following order:
from head to foot, left to right, and top to bottom.
3) All the gross slices and histology slides
numbers
1were assigned corresponding
3
4
A gross pathology slice, unicassettes for tissue embedding, and VS
10A
Slice 10
10A
4) the glass histology slides were digitized by virtual microscopy.
Virtual slide : 10A
Gross pathology slice
CT image
All kinds of images can be
viewed seamlessly.
Virtual slide
A resected case of HCC: macroscopically, this case is basically
nodular type, but some parts are the confluent multinodular type.
Figure (CT images)
CT imaging: Radiologists observe several hundreds of
images by “paging” as shown in this movie.
Movie on the gross pathological images: Just like radiologists,
pathologists, too, can observe gross pathological imaging by paging.
Movie of the gross pathological images from arbitrary direction
Constitution
1. Background
2. Aim
3. Materials and methods
3a. Pathology report form
3b. Seamlessly viewing images
3c. Medical library
4. Result
5. Conclusion
[Materials and Methods 3c]
Using the HIS, a medical library was set up containing research papers
about the cases in our hospital.
Lib 11 Blood vessels
Lib 12 Heart
Lib 13 Diseases of blood cells, lymph nodes, spleen, and thymus
Lib 14 The lung
Lib 15 Head and neck
Lib 16 The gastrointestinal tract
Incidence of lymph node metastasis in cases of early gastric carcinoma (Treatment of early gastric carcinoma by ESD)
Gastric carcinoma and lymph node dissection level
Risk level of GIST and FDG-PET
Lib 17 Liver and biliary tract
HCC and FDG-PET
Lib 18 The pancreas
Lib 19 The kidney
Lib 20 The lower urinary tract and male genital system
Lib 21 The female genital tract
Lib 22 The breast
link
Lib 23 The endocrine system
Lib 24 The skin
Lib 25 Bones, joints, and soft tissue tumors
Lib 26 Peripheral nerve and skeletal muscle
Lib 27 The central nervous system
Lib 28 The eye
Constitution
1. Background
2. Aim
3. Materials and methods
3a. Pathology report form
3b. Seamlessly viewing images
3c. Medical library
4. Result
5. Conclusion
[Result]
The inclusion of a wide range of information in the pathological report
form and the use of a standardized method for viewing digital images
facilitated the understanding of each case and helped easy comparison
of radiological and pathological images.
The incorporation of non-pathomorphological data, in connection with
evidence from our library, helped improve the reliability of the comments
in the pathology reports.
The methods presented here facilitate the research of radiology and
pathology.
We show the result of HCC study obtained by the present methods.
HCC and glucose metabolism (FDG-PET)
Figure. Gross types of HCC: type 1, 2x, 2a, 2b, 3, and 4
Type 1
Type 2x
Type 2a
Type 2b
Type 3
Type 4
Figure 3. Morphogenetic changes in the gross types of HCC:
Relation between the 4 gross types--type 1 (replacing growth type), type 2a
(macro-subnodular type), type 2b (micro-subnodular type), type 3 (confluent
multinodular type), and type 4(massive type);
deep color: pure form, light color: mixed form ; [% of pure form]
Type 4
[40.9]
[57.1]
8
Type 3
9
6
11
2
3
9
71 Type 2a
[84.2]
8
[72.7]
Type 1
3
9
2
Type 2x
39 Type 2b
Table 4 Relation between HCC gross type, size, and necrosis in HCC
cases with TAE
Gross type No. of cases (%)
Tumor size (cm)
Tumor necrosis (%)
1
2 (2.0)
2.4±0.5
15.0±21.24)
2a
2b
2x
3
4
44 (44.9)
23 (23.5)
5 (5.1)
15 (15.3)
9 (9.2)
3.3±2.2
3.9±2.1
2.3±1.7
3.5±2.3
10.6±3.7
87.8±17.55)
69.8±24.76)
88.0±13.07)
59.3±32.1
43.9±20.68)
1) HCC: Hepatocellular carcinoma, 2) TAE: transcatherter arterial embolization, 3) Gross
type 1: replacing growth type, 2a: macro-subnodular type, 2b: micro-subnodular type,
3: confluent multinodular type, 4: massive type
5) vs. 6) P=0.0009, 4) vs. 6) p=0.0059, 4) vs. 7) p=0.0059, 6) vs. 8) p=0.0092
Table 5 Relation between HCC gross type, DD-score, DD-G, and FDG
uptake in HCC cases without TAE (same cases in Table 3)
Gross type
DD-score
DD-G
4.2±1.7
FDG uptake (No. of cases)
1.2±0.2 (3)12)
1
7.7±1.7
2a
2b
2x
3
10.5±2.58)
14.0±3.29)
8.5±0.7
13.7±2.2
2.6±1.010)
4.4±2.311)
4.3±3.0
4.2±2.6
1.7±0.7 (17)13)
2.6±1.0 (13)14)
- (0)
1.9±0.6 (7)
4
15.4±1.9
1.4±0.8
5.4±2.1 (4)
HCC: Hepatocellular carcinoma, 2) DD-score: dedifferentiation score, 3) DDG: dedifferentiation gradient, 4) FDG: 18F-fluorodeoxyglucose, 5) FDG ratio: FDG-SUVmax
of HCC per background FDG value, 6) TAE: transcatherter arterial embolization, 7) Gross
type 1: replacing growth type, 2a: macro-subnodular type, 2b: micro-subnodular type, 3:
confluent multinodular type, 4: massive type
8) vs. 9) p<0.001, 10) vs. 11) p=0.0004, 13) vs. 14) p=0.0071, 12) vs. 13) p=0.0305
Constitution
1. Background
2. Aim
3. Materials and methods
3a. Pathology report form
3b. Seamlessly viewing images
3c. Medical library
4. Result
5. Conclusion
Conclusion
The format of the pathology report form with seamless
image viewing described in this study is expected to
promote deeper integration of comprehensive information
in evolving HIS and contribute positively to education,
research, and patient care.
Thank you very much for your attention
ご清聴、ありがとうございました。
New information system in Our New Hospital (2013)
to utilize accumulated data in HIS
Today’s presentation:
#Structured pathology report
#Seamless viewing images
Lab. system
#Medical library
Statistical data
専用Data Warehouse
RIS・PACS
Search engine
Case data
Electronic
patient record
Data
optimization
Data base
Pathology system